New treatment combinations are improving the outlook for people with pancreatic cancer.

Each year in the United States, more than 46,000 people
are diagnosed with pancreatic cancer. The pancreas gland is
shaped like a tadpole (with a head, body and tail) and sits behind
the stomach. It helps the digestive system break down and
absorb fats and proteins in foods. The pancreas also produces
hormones such as insulin, which controls blood sugar.

In this booklet we discuss the most common type of
pancreatic cancer, called ductal adenocarcinoma.

Treatment for pancreatic cancer is based on whether or
not the cancer is localized (confined to the pancreas),
involves major blood vessels or has spread to other parts
of the body. If the tumor has spread (metastasized)
beyond the pancreas, then treatments other than surgery
are used.

Doctors often prescribe chemotherapy, targeted treatments,
radiation or a combination of these therapies for people with
metastatic pancreatic cancer. Targeted treatments destroy
cancer cells by focusing on specific cell mechanisms thought
to be important for the growth and survival of tumor cells.
These medications are designed to spare healthy tissues in
the hope of causing less severe side effects.

Surgery

People receiving surgical treatment for their pancreatic cancer
benefit most from working with a doctor who specializes in
treating this cancer and performs many pancreatic surgeries.

There are different types of surgical procedures to remove
pancreatic tumors:

Whipple procedure. This procedure removes a portion of the
pancreas called the “head,” along with the gallbladder, part
of the stomach, part of the small intestine and the bile duct.
A portion of the pancreas is left in place to produce digestive
juices and insulin.

Total pancreatectomy. This operation removes the entire
pancreas, part of the stomach and small intestine, the bile
duct, gallbladder, spleen and nearby lymph nodes.

Distal pancreatectomy. The body and tail, or distal end,
of the pancreas and usually the spleen are removed in
this procedure.

If the cancer has spread and cannot be removed, surgeons
can perform different types of palliative surgery. These types
of procedures are designed to relieve symptoms and improve
quality of life. One such procedure, described on the “Managing Side Effects” page in
the discussion on jaundice, relieves a blocked bile duct by
inserting a tube called a stent to drain the fluid.

Chemotherapy and Targeted Treatments

One standard treatment for pancreatic cancer is a
chemotherapy drug called gemcitabine (Gemzar and others).
It can shrink the cancer, ease symptoms and help patients live
longer. Gemcitabine is approved by the U.S. Food and Drug
Administration as a first-line treatment (first treatment given)
for patients whose cancer has spread and cannot be treated
with surgery.

To increase survival, gemcitabine often is combined with other
medications such as albumin-bound paclitaxel (Abraxane).
Sometimes doctors combine gemcitabine with oxaliplatin
(Eloxatin and others) or capecitabine (Xeloda and others).
Gemcitabine can also be used by patients already treated
with fluorouracil (5-FU), another type of chemotherapy. For
certain patients, FOLFIRINOX, a combination of folinic acid
(leucovorin), 5-FU, irinotecan (Camptosar and others) and
oxaliplatin, is used as the first treatment for pancreatic cancer.

There is one targeted treatment called erlotinib (Tarceva
and others) that is given with gemcitabine for the treatment
of pancreatic cancer. This combination works by blocking
processes in tumor cells that help the cancer grow and spread.

There are many ways that your health care team can
manage the side effects of pancreatic cancer or its
treatment. It’s important to let your doctor or nurse know
if you experience any of the symptoms discussed in this
section. Together, you can make the best decisions for
your care.

Pain

Pain can occur if the tumor presses on nerves or other organs
near the pancreas. How strong the pain is—and how often
it happens—depends on several factors: the position of the
tumor, how much the cancer has grown, whether or not it has
affected nerves or other organs and the location of any tumors
that have spread outside of the pancreas.

Pain is treatable, and getting help for it can greatly improve your quality of life. People who are pain-free eat better, sleep better and cope with chemotherapy better than those who have severe pain.

Depending on the level of pain, doctors prescribe various
medications. Even the most severe pain can be managed
effectively with opioids such as morphine. Although opioids
themselves can cause side effects such as constipation,
sleepiness or itching, there are drugs that can ease these
symptoms as well.

Another effective pain relief method for some people with
pancreatic cancer is a celiac plexus block. This is a procedure
in which the celiac plexus (a group of nerves near the
pancreas) is numbed with medication injected with a needle.
For many patients, this procedure reduces pain and the need
for other pain medications.

If pain comes from the pancreatic tumor itself or from tumors
that have spread to the bone, radiation may be an option. For
some people, relaxation exercises and mind/body techniques,
such as deep breathing and meditation, may also help manage
pain. Some cancer treatment centers have programs to teach
people with cancer and their caregivers the basics of these
techniques. The professional oncology social workers at
CancerCare can help you learn these techniques as well.

Jaundice

In this condition, bile—a substance produced by the liver
that helps break down fats in the intestines—builds up to
unsafe levels. Jaundice is common in people with pancreatic
cancer that begins in the head of the pancreas. It is caused by
blockage of the bile duct, a small tube that carries bile from
the liver to the small intestine. Jaundice can cause loss of
appetite, weight loss, nausea and itching as well as yellowing
of the skin and eyes. If the bile duct is blocked, doctors insert a
tube, called a stent, into the bile duct. The tube helps bile drain
into the intestine.

If you have fever, chills, abdominal pain or any return of
jaundice after receiving a stent, let your health care team know
right away. These symptoms can be signs of an infection or a
problem with the stent.

Intestinal Blockages

Some people with advanced pancreatic cancer may develop
blockages in the intestines. This can happen if the tumor
blocks the intestines or if nerve damage or opioids used
for pain relief prevent the intestines from working properly.
Intestinal blockages can cause eating difficulties and vomiting.
For people using opioids, changing the dosage often helps
relieve Intestinal blockages.

Sometimes, surgery or stents are used to treat intestinal
blockages. Another option is inserting a tube into the stomach
to allow fluids to drain. This can help relieve vomiting.

Doctors also can drain fluid called ascites from the abdomen
with a hollow needle inserted through the skin. If the fluid
quickly builds up again, a permanent tube, or catheter, may be
needed to drain fluid continually.

Discussing Pain With Your Doctor

The more detail you can give your doctor about the kind of
pain and how much pain you feel, the better he or she will be
able to treat it. Here are some tips that can help:

• Keep a diary with notes about how your pain affects you.
That way, you don’t have to rely on memory to give your
doctor accurate information.

• Every time you meet with your doctor, discuss whether
or not you are experiencing pain. It is part of your “vital
signs” (just like blood pressure and heart rate), and it
should be checked.

• Use a scale of 0 (no pain) to 10 (very bad pain) to rate
your pain. This is a good way to measure pain and find
out how well your medication is working to relieve it.

• Tell your doctor whether anything makes the pain worse.
For example, does standing, sitting or getting up from a
seated position make it hurt more?

• Talk about whether anything relieves the pain. For
instance, do you feel better if you apply ice or a
heated compress to the area or when you lie down
or walk around?

• Let your doctor know how much relief you are getting
from pain medications or other methods you use. Does
your pain medication provide you with enough relief?
Does it wear off before it’s time for your next dose? Are
you having any unpleasant side effects from using it?

Because the pancreas plays a key role in digestion, pancreatic
cancer can cause a number of nutrition-related side effects.
These symptoms may be a result of the cancer itself or
its treatment. The right nutrition can help you maintain
your weight, strength and quality of life as you go through
treatment for pancreatic cancer.

Among the most common nutrition-related side effects for
people with pancreatic cancer are difficulty digesting or
absorbing nutrients from food, nausea and vomiting, loss of
appetite, changes in taste, feeling full early, pain with eating,
fatigue and changes in bowel movements. If eating poses a
challenge, let your health care team know and ask to see a
registered dietitian.

The following tips can help you cope with nutrition-related side
effects of pancreatic cancer:

Eat small, frequent meals. Try to eat about six to eight times
a day.

Plan meals and snacks. Each day, take time to plan when and
what you will be eating the next day. This will help you cope with
times when you don’t feel hungry or don’t know what to eat.

Drink plenty of fluids. Most people need to drink at least six to
eight cups of water or other fluid every day. Don’t include beer,
wine or other alcoholic drinks in the daily tally.

Limit the amount of fat in your diet. High-fat foods can
contribute to changes in bowel habits or to feeling full quickly.

About Pancreatic Enzymes

A healthy pancreas secretes a number of substances called
enzymes that help with digestion. When a person has
pancreatic cancer, the cancer or the treatments for it (including
surgery) may affect the ability of the pancreas to secrete
needed enzymes.

Prescription pancreatic enzymes are available. Everyone
needs a different amount of pancreatic enzymes to help with
digestion, and pancreatic enzymes vary from brand to brand.
If you have been prescribed pancreatic enzymes, it may take
some time to find the brand and dose that work best for you.
If you experience any of the following symptoms, talk with
your doctor:

Q. Has progress been made in increasing survival for
people with pancreatic cancer?

A. Improving pancreatic cancer survival has been
particularly challenging. The cancer tends to be
detected late, when it has already spread, and it can resist the
best available treatments because of its complex biology and
genetics. However, researchers are making strides in treating
pancreatic cancer. Importantly, they are continually developing
better ways to study pancreatic cancer through clinical trials.
These carefully controlled studies are the standard by which
we measure the effectiveness of new treatments and their
impact on patients’ survival and quality of life. Clinical trials
also offer an additional treatment option. For these reasons,
doctors and researchers urge people with pancreatic cancer to
take part in clinical trials.

Q. What are the treatment and prognosis for a
neuroendocrine tumor that begins in the pancreas?

A. Neuroendocrine tumors that start in the pancreas
are quite different from the pancreatic cancer tumors
(adenocarcinomas) discussed in this booklet. Neuroendocrine
tumors affect cells in the pancreas that produce hormones,
including insulin. The pancreatic cancer we have been
discussing affects ductal cells—pancreatic cells that drain
substances called enzymes from the pancreas into the bowel.
Neuroendocrine tumors appear to grow more slowly and in
a different way than other pancreatic tumors. They are often
removed surgically, followed by treatment with hormones
or targeted drugs such as everolimus (Afinitor) or
sunitinib (Sutent).

Q. For a person with pancreatic cancer who
has already been treated with surgery and
chemotherapy, what are the next steps to take?

A. The standard procedure is to have follow-up CT scans
every four to six months. In addition, blood tests are
used to check levels of CA19-9, a substance released by
pancreatic tumors. It is used as a marker of tumor growth. If
the level of CA19-9 is high before surgery and then rises after
surgery, extra tests may be needed to see if the tumor
has returned.

Your Support Team

When you are diagnosed with pancreatic cancer, you’re faced
with a series of choices that will have a major effect on your
life. Your health care team, family members and friends will
likely be an invaluable source of support at this time. You can
also turn to these resources:

Oncology social workers provide emotional support for people
with cancer and their loved ones. These professionals can
help you cope with the challenges of a cancer diagnosis and
guide you to resources. CancerCare offers free counseling
from professional oncology social workers who understand the
challenges faced by people with cancer and their caregivers.
We can work with you one-on-one to develop strategies for
coping with treatment and its side effects.

Oncology social workers can also help you communicate with
your doctor and other members of your medical care team
about the health care issues that are important to you.

Support groups provide a caring environment in which you
can share your concerns with others in similar circumstances.
Support group members come together to help one another,
providing insights and suggestions on ways to cope. At
CancerCare, people with pancreatic cancer and their families
can participate in support groups in person, online or on
the telephone.

Financial help is offered by a number of organizations to
assist with cancer-related expenses such as transportation to
treatment, child care or home care.

To learn more about how CancerCare helps, call us at
800-813-HOPE (4673) or visit www.cancercare.org.

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The information presented in this publication is provided for your general information only. It is not intended as medical advice and should not be relied upon as a substitute for consultations with qualified health professionals who are aware of your specific situation. We encourage you to take information and questions back to your individual health care provider as a way of creating a dialogue and partnership about your cancer and your treatment.